191601613-6-14-2024-11-AS-RORN-D6DU4A-20240619151448

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191601613
Report Date: 06/14/2024
Date Signed: 06/14/2024 12:03:12 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/05/2024 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20240605081042

FACILITY NAME:	WILMINGTON GARDENS		FACILITY NUMBER:	191601613
ADMINISTRATOR:	FLORES,V.ANDT.		FACILITY TYPE:	735
ADDRESS:	1311 WEST ANAHEIM STREET		TELEPHONE:	(310) 835-6366
CITY:	WILMINGTON	STATE: CA	ZIP CODE:	90744
CAPACITY:	48	CENSUS: 41	DATE:	06/14/2024
		UNANNOUNCED	TIME BEGAN:	10:27 AM
MET WITH:	Vic "Jun" Flores		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Illegal eviction
Staff did not meet infection control requirements

INVESTIGATION FINDINGS:

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On 06/14/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced visit to deliver finding to the facility listed above. LPA met with Administrator, Vic 'Jun' Flores, and the purpose of today's visit was explained.

On a previous visit conducted on 06/12/24, LPA toured the facility, interviewed Staff S1-S3, interviewed Clients C1-C5, and received documents pertinent to the investigation. The documents received and reviewed include a Staff Roster, Resident Roster, Client Admission Agreement, Client Needs & Service Plan, Client Appraisal, and Special Incident Reports (SIR). The Administrator emailed additional documents requested by LPA. The additional documents received include updated Needs and Service Plan, Physicians Report, and Infection Control Plan.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240605081042

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WILMINGTON GARDENS	FACILITY NUMBER: 191601613
	VISIT DATE: 06/14/2024

NARRATIVE

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Allegation: Illegal Eviction
It is alleged the administrator is refusing to accept a client back from the hospital due to not having an isolation room.
During record review, LPA observed there has been no eviction notices that have been issued to any Clients.
During an interview with the Administrator S1, was asked why Client C1 was denied returning to the facility, S1 stated they asked the hospital if they could keep them an extra day are two because they did not have an isolation room available. S1 informed LPA that Client rooms are being painted and repaired if necessary and while the room is being painted the clients are moved to the isolation room.
During interviews with Staff (S2-S3), were asked if there was a time a client was denied returning to the facility, two (2) out of two (2) stated to their knowledge that has not happened.
During interviews with Clients (C1-C5), were asked if there was a time when the facility refused to allow a client to return to the facility, five (5) out of five (5) stated they have not experienced that and not have not heard of that happening.
During today’s visit, LPA observed Client C1 has returned to the facility from the hospital. LPA asked C1 if there were any issues returning to the facility after their time in the hospital, C1 stated there were no issues and they were happy to be back.

Allegation: Staff did not meet infection control requirements

It is alleged a client with a communicable disease was not accepted back into the facility because they did not have accommodations to isolate the Client.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20240605081042

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WILMINGTON GARDENS	FACILITY NUMBER: 191601613
	VISIT DATE: 06/14/2024

NARRATIVE

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During today’s visit, LPA observed staff wearing masks and cleaning high frequency touch surfaces.
During record review, LPA reviewed the facility’s Client Quarantine Protocols, that states Room 7 will be used as a Quarantine Room. During the facility tour, LPA observed they do have a quarantine room.
During file review, LPA reviewed the facility’s Plan for Epidemic Outbreak Specific to Covid-19 Mitigation Plan Report that states on page 8 facility has plans to isolate or quarantine residents as needed in a designated Quarantine Room.
During an interview with the Administrator S1, was asked if there is a room to quarantine clients who are diagnosed with a communicable disease, they stated the facility does have an isolation room. Additionally, they stated they have been painting clients’ rooms and while their rooms are being painted, the clients are relocated to the isolation room.
During interviews with Staff (S2-S3), were asked if the facility has a quarantine room, two (2) out of two (2) stated the facility has a quarantine room.
During interviews with Clients (C1-C5), were asked if the facility has a quarantine room, five (5) out of five (5) stated they believe the facility has a quarantine room.

During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted with Administrator, Vic 'Jun' Flores, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC9099 (FAS) - (06/04)

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